Employee Health Screening Form

Employee Health Screening Form — Form Fields

This healthcare template includes 6 fields. Conduct a periodic health screening for healthcare workers or other employees to monitor wellness and identify work-related health risks. Supports occupational health programs and workforce safety initiatives. Documents screening results for HR and occupational health records. Free to customize and use on ZenBuild.

• Employee Full Name (text, required)
• Job Title and Department (text, required)
• Do you currently have any symptoms of illness? (multiple choice, required) — options: No – feeling well, Yes – mild symptoms, Yes – significant symptoms
• Vaccinations up to date (select all that apply) (checkboxes, optional) — options: Influenza (current season), Hepatitis B, MMR (measles, mumps, rubella), COVID-19, Tdap (tetanus, diphtheria, pertussis)
• Overall physical wellbeing this week (rating, required)
• Have you had any work-related injuries in the past 30 days? (dropdown selection, required) — options: No, Yes – reported to occupational health, Yes – not yet reported